Provider Demographics
NPI:1942492731
Name:MATTESON, SETH MICHAEL (IDC)
Entity Type:Individual
Prefix:MR
First Name:SETH
Middle Name:MICHAEL
Last Name:MATTESON
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PSC BOX 20116
Mailing Address - Street 2:MARINE FORCES SPECIAL OPERATIONS COMMAND/ MSOSG
Mailing Address - City:CAMP LEJEUNE
Mailing Address - State:NC
Mailing Address - Zip Code:28542
Mailing Address - Country:US
Mailing Address - Phone:910-450-6823
Mailing Address - Fax:
Practice Address - Street 1:MARINE FORCES SPECIAL OPERATIONS COMMAND/ MSOSG
Practice Address - Street 2:PSC BOX 20116
Practice Address - City:CAMP LEJEUNE
Practice Address - State:NC
Practice Address - Zip Code:28542
Practice Address - Country:US
Practice Address - Phone:910-450-6097
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-15
Last Update Date:2008-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman